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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' Permit Njp 4-1% , r=te; P _� (Complete in Triplicate) P o. r�l ' This Permit Expires 1 Year From Date Issued Date Issued ;% -->!i! L__-_--7� ----------------------------------- ;'s Application is hereby made to the San-Joaquin Local Health District for a permit to construct and install the work herein described. This application is made incompliance with County Ordinance No. 549 and existing Rules and Regulations: JOB`.ADDRESS%LOCATION ._ o-6_Q 1---- __- _R�OG (�-N-------Rt)-------------------CENSUS TRACT _. r_. ..... Owner's Name ----FR)9-N-K-------P---------GO-N�_-��-I.Q- ------,--- -------Phone.-57c7 -,3�}�3_7 Address ---- _O(0- j-----------------i��_R-RQG--Q--N----------- ------------ City �--i-1_P�-P4--------------------------------------•__. ---•--•--- Contractor's Name -----Qrnlnj�(� License # ------ :-- ------ Phone -------------------------- Installation will serve: Resider a partment House-❑ Commercial:❑Trailer Court C] ;M`o`tel ❑Other -------------------------------------------- 3 Number of living units.----/----- Number of bedrooms--------Garbage Grinde�. _ Lot Size _.AhR)FnE>�.----------- I . Water Supply: Public System and name -------------- =------------------------------------------------• ;.' ------------- Private Character,of,soil to a. depth.of 3 feet: ,, -Sand' _ _Silt fl. Clay ❑ Peat❑ Sandy Lodm ❑ Clay Loam ❑,.Y Hardpan ❑ Adobe ❑ Fill Material ---/V,;;jlf yes, type____----------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: {No septic tank or seepage jl it permitted if public sewer is availab within 200 feet,j PACKAGE TREATMENT [ SEPTIC TANK[ ] Size----- ---------- ------- --___.-..,::-: --r;Liquid_Depfih '-----------_--•- ----- CapacitY----- ------------ TYPe --�---- '-- Material----------- -- ,N . Compartments c ! Foundation'-1__._ ' �F= Pro Line ----------------------Distance to nearest: Well _--___----__i_--�---------------- - � - - - - � .P- k LEACHING LINE [ ] No. of Lines ----------- _-- Length of-each line------------------- !Total Length ________________.._-.-___ Box ------------ Type Filter Aciterial '^`f ----.-Depth Filter'J 'trial ----- ___ ----- Distance to nearest: Well ___ __________________ Foundation ____'"�-.._ . ____ Property Line- ---------:_____.-------- SEEPAGE PIT Depth ___ Diame r ________________ Number --- ------------------- ____ Rock--F)Iled Yes ❑ No ❑ Water Table Depth _-__----_ __ - L ------ -------------------------Rock Size -------- - -- ----------- ------ Distance to nearest: Well ___ _ _ .- { �. ` Foundation Prop. Line ----------- -- REPAIR/ADDITION(Prev. Sanitation Permit# ------------ -------------- -------------------- --.:--..aate--_--------------------------------1 Septic Tank (Specify Requirements) --------- I�� _C `------PQ RT-60 N------6-F----- f_ l_ �.:_:_---S n� I ' Disposal Field {Specify Requirements) -l��Q ------ �}L --cao��_-__--REF1q�---- L P_n�6----?C- .� - i D ---------------------------------- ------ Ir n r�v.ES -- ----- - ----- - %r J r --X (Draw existing and required a`dditiiin on reverse side) I hereby certify that•I have prepared this application and that the work will be done in accordance with Sain-�oaquin County Ordinances, State Laws;and Rules and Regulations of the Son IJoaquin Local Health District. Home owner or liven- sed agents signature cern es.the following: d "I certif n the pe rmance o the work for w h this permit is issued,_I shall not employ any person in such manner as to bec m ubject to orkL-0 ompensati.on sof California.", - � L Signed -- -- ---------- - Owner ria = ,� BY -------------------------------------- - --------------------- --------- y= ' Title --- (If other than owner)" fel } -FOR DEPARTMEW-,USE ONLY APPLICATION ACCEPTED BY -f -i- ------------------------ r `' =DATE �� ------- -- BUILDING PERMIT ISSUED " ----------- ;----- •--------- f--t - - --- -- TE ADDITIONAL COMMENTS'-//' _` � i- - '--------- -- - - ---------------=----- '-----------.... ' -'— p - ------ ------------------- -------- -------------------- -- --------------- --- ------- -- --- ---- - ----- ---------- -------- -- --------- ----- ---- ------ ----------------------- ---- --- ------ _ - - _= - Final Inspection by ------ • Date _..l ----------- SAN—JO --. SAN JOAQUIN 4LOCA'L�HE_/�LTxFi= DIST ICT E. H. 9 1-'68 Rev. 5M